Pharmacologic Treatment of Hypertensive Urgency in the Outpatient Setting: A Systematic Review.

BACKGROUND: Hypertensive urgency (HU), defined as acute severe uncontrolled hypertension without end-organ damage, is a common condition. Despite its association with long-term morbidity and mortality, guidance regarding immediate management is sparse. Our objective was to summarize the evidence examining the effects of antihypertensive medications to treat. METHODS: We searched the PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), Database of Abstracts of Reviews of Effects (DARE), Cochrane Database of Systematic Reviews, Web of Science, Google Scholar, and Embase through May 2016. STUDY SELECTION: We evaluated prospective controlled clinical trials, case-control studies, and cohort studies of HU in emergency room (ER) or clinic settings. We initially identified 11,223 published articles. We reviewed 10,748 titles and abstracts and identified 538 eligible articles. We assessed the full text for eligibility and included 31 articles written in English that were clinical trials or cohort studies and provided blood pressure data within 48 h of treatment. Studies were appraised for risk of bias using components recommended by the Cochrane Collaboration. The main outcome measured was blood pressure change with antihypertensive medications. Since studies were too diverse both clinically and methodologically to combine in a meta-analysis, tabular data and a narrative synthesis of studies are presented. RESULTS: We identified only 20 double-blind randomized controlled trials and 12 cohort studies, with 262 participants in prospective controlled trials. However, we could not pool the results of studies. In addition, comorbidities and their potential contribution to long-term treatment of these subjects were not adequately addressed in any of the reviewed studies. CONCLUSIONS: Longitudinal studies are still needed to determine how best to lower blood pressure in patients with HU. Longer-term management of individuals who have experienced HU continues to be an area requiring further study, especially as applicable to care from the generalist.

iPod™ technology for teaching patients about anticoagulation: a pilot study of mobile computer-assisted patient education.

AIM: To determine whether an educational strategy using a handheld, multimedia computer (iPod™) is practical and sustainable for routine office-based patient educational tasks. BACKGROUND: With the limited amount of time allotted to the office encounter and the growing number of patient educational tasks, new strategies are needed to improve the efficiency of patient education. Education of patients anticoagulated with warfarin is considered critical to preventing complications. Despite the dangers associated with the use of warfarin, educational practices are variable and often haphazard. METHODS: During a four-month period, we examined the implementation of a three-part series of iPod™-based patient educational modules delivered to anticoagulated patients at the time of routine INR (International Normalized Ratio) blood tests for outpatients on the anticoagulation registry at an urban community health center. FINDINGS: A total of 141 computer module presentations were delivered to 91 patients during the four-month period. In all, 44 patients on the registry had no INR checkups, and thus no opportunity to view the modules, and 32 patients had at least three INR checkups but no modules were documented. Of the 130 patients with at least one INR performed during the study period, 22 (16.9%) patients completed all three modules, 91 (70.0%) patients received at least one module, and nine (7.6%) patients refused to view at least one module. Neither of the two handheld computers was lost or stolen, and no physician time was used in this routine educational activity. Patients reported that the audio and visual quality was very good, (9.0/10); the educational experience of the patient was helpful (7.4/10) compared with the patient's previous warfarin education (6.3/10), and the computer strategy extended the INR visit duration by 1-5 min at most. CONCLUSIONS: The computer-assisted patient educational strategy was well received by patients, and uptake of the intervention by the clinic was successful and durable. The iPod™ strategy standardized the educational message, improved clinic efficiency, and helped this busy clinic meet its educational goals for patient education.

Providing a Spanish interpreter using low-cost videoconferencing in a community health centre: a pilot study using tablet computers.

BACKGROUND: The advent of more mobile, more reliable, and more affordable videoconferencing technology finally makes it realistic to offer remote foreign language interpretation in the office setting. Still, such technologies deserve proof of acceptability to clinicians and patients before there is widespread acceptance and routine use. OBJECTIVE: We sought to examine: (1) the audio and video technical fidelity of iPad/Facetime(TM) software, (2) the acceptability of videoconferencing to patients and clinicians. METHODS: The convenience sample included Spanish-speaking adult patients at a community health care medicine clinic in 2011. Videoconferencing was conducted using two iPads(TM) connecting patient/physician located in the clinic examination room, and the interpreter in a remote/separate office in the same building. A five-item survey was used to solicit opinions on overall quality of the videoconferencing device, audio/video integrity/fidelity, perception of encounter duration, and attitude toward future use. RESULTS: Twenty-five patients, 18 clinicians and 5 interpreters participated in the project. Most patients (24/25) rated overall quality of videoconferencing as good/excellent with only 1 'fair' rating. Eleven patients rated the amount of time as no longer than in-person, and nine reported it as shorter than inperson. Most patients, 94.0% (24/25), favoured using videoconferencing during future visits. For the 18 clinicians, the results were similar. CONCLUSIONS: Based on our experience at a singlesite community health centre, the videoconferencing technology appeared to be flawless, and both patients and clinicians were satisfied. Expansion of videoconferencing to other off-site healthcare professionals should be considered in the search for more cost-effective healthcare.

The digital divide at an urban community health center: implications for quality improvement and health care access.

Health care policy encourages better electronic connectivity between patient and the office practice. However, whether patients are able to partner with the practice in using communication technologies is not known. We sought to determine (1) the proportion of clinic patients who use internet and cell phone text messaging technologies, (2) the level of patient interest in using these technologies for the purpose of managing clinical appointments and patient education. Consecutive adult patients, clinicians and staff at an urban community health center were surveyed during a one-week period in order to estimate the frequency of technology use by patients. A total of 308 survey cards were collected during the designated week (response rate of 85% (308/362). One-third (34.0%, 105) of surveyed patients used the internet and text messaging daily or weekly, while nearly two-thirds (59.7%, 182) never used these technologies. There were no racial or gender differences in the proportion of patients who used the internet daily or weekly. In contrast, African-Americans used text messaging more often than whites (28.2 vs. 21.4%, P < .05), and females more than males (30.8 vs. 18.5%, P < .05). Younger patients (>50) used the internet and text messaging more often than older patients (50.6 vs. 16.6%, 44.3 vs. 7.3%, respectively). Despite the low use of both technologies, patient's interest in managing clinic appointments was high (40.3% for the Internet and 56.8% for text messaging). Clinicians and staff estimated patient's daily/weekly use of internet and cellphone messaging at 40.3% (± 22.0), and 56.8% (± 25.7), respectively. Most patients at this urban community health center reported never using the internet or cell phone text messaging. Clinicians overestimated technology use by patients. Planning for clinic infrastructure, quality improvement, and patient education should include assessment of technology use patterns by patients.

The impact of drug samples on prescribing to the uninsured.

OBJECTIVE: To determine whether drug samples are associated with physicians prescribing fewer generic, less costly medications. METHODS: We conducted a retrospective study at a large university-affiliated internal medicine practice containing over 70 physicians. Using a pharmacy database, we identified all prescriptions written to uninsured or Medicaid patients that belonged to one of four classes of chronic medications. For the 9 months before and after the clinic closed its drug sample closet, we calculated the percentage of medications prescribed as generics and the mean cost of a 30-day supply of a prescription. RESULTS: Of 8911 prescriptions, 1973 met inclusion criteria. For uninsured patients, the percentage of medications prescribed as generics rose from 12% to 30% after the clinic closed its drug sample closet (P = 0.004). By consecutive three month periods, the percentage of prescribed generic medications rose steadily to a maximum of 40% (P < 0.001). For Medicaid patients, there was no significant change in generic prescribing (63% generic with samples versus 65% generic without samples, P = 0.42). Two factors were associated with generic prescribing in logistic regression: the absence of drug samples (OR 4.54, 95% CI 1.37-15.0) and the prescriber being an attending physician (OR 5.26, 95% CI 2.24-12.4). There was no statistically significant change in cost for either group. CONCLUSIONS: Physicians were three times more likely to prescribe generic medications to uninsured patients after drug samples were removed from the office. Drug samples may paradoxically lead to higher costs if physicians with access to samples prescribe more brand-name only drugs.

Best strategies for patient education about anticoagulation with warfarin: a systematic review.

BACKGROUND: Patient education is an essential component in quality management of the anticoagulated patient. Because it is time consuming for clinicians and overwhelming for patients, education of the anticoagulated patient is often neglected. We surveyed the medical literature in order to identify the best patient education strategies. STUDY SELECTION: Two reviewers independently searched the MEDLINE and Google Scholar databases (last search March 2007) using the terms "warfarin" or "anticoagulation", and "patient education". The initial search identified 206 citations, A total of 166 citations were excluded because patients were of pediatric age (4), the article was not related to patient education (48), did not contain original data or inadequate program description (141), was focused solely on patient self-testing (1), was a duplicate citation (3), the article was judged otherwise irrelevant (44), or no abstract was available (25). DATA EXTRACTION: Clinical setting, study design, group size, content source, time and personnel involved, educational strategy and domains, measures of knowledge retention. DATA SYNTHESIS: A total of 32 articles were ultimately used for data extraction. Thirteen articles adequately described features of the educational strategy. Five programs used a nurse or pharmacist, 4 used a physician, and 2 studies used other personnel/vehicles (lay educators (1), videotapes (1)). The duration of the educational intervention ranged from 1 to 10 sessions. Patient group size most often averaged 3 to 5 patients but ranged from as low as 1 patient to as much as 11 patients. Although 12 articles offered information about education content, the wording and lack of detail in the description made it too difficult to accurately assign categories of education topics and to compare articles with one another. For the 17 articles that reported measures of patient knowledge, 5 of the 17 sites where the surveys were administered were located in anticoagulation clinics/centers. The number of questions ranged from as few as 4 to as many as 28, and questions were most often of multiple choice format. Three were self-administered, and 2 were completed over the telephone. Two reports described instruments along with formal testing of the validity and reliability of the instrument. CONCLUSION: Published reports of patient education related to warfarin anticoagulation vary greatly in strategy, content, and patient testing. Prioritizing the educational domains, standardizing the educational content, and delivering the content more efficiently will be necessary to improve the quality of anticoagulation with warfarin.

Exploring the educational value of clinical vignettes from the Society of General Internal Medicine national meeting in the internal medicine clerkship: a pilot study.

INTRODUCTION: Whether the clinical vignettes presented at the Society of General Internal Medicine (SGIM) annual meeting could be of educational value to third year students in the Internal Medicine clerkship has not been studied. OBJECTIVE: To explore the relevance and learning value of clinical vignettes from the SGIM national meeting in the Internal Medicine clerkship. SETTING: Third year Ambulatory Internal Medicine clerkship at one academic medical center (academic year 2005 to 2006). METHODS: Students were introduced to the clinical vignette and oriented to the database of clinical vignettes available through the SGIM annual meeting website. Students then reviewed 5 to 10 clinical vignettes using a worksheet, and rated the learning value of each vignette using a 5-point Likert scale (1=least, 5=greatest). A single investigator evaluated congruence of the vignette with the Clerkship Directors of Internal Medicine (CDIM)-SGIM curriculum to assess relevance. MAIN RESULTS: A total of 42 students evaluated 371 clinical vignettes from the 2004 and 2005 meetings. The clinical vignettes were curriculum-congruent in 42.6% (n=175), and clearly incongruent in 40.4% (n=164). The mean rating for learning value was 3.8 (+/-1.0) (5 signifying greatest learning value). Curriculum-congruent vignettes had a higher mean learning value compared with curriculum-incongruent vignettes (4.0 vs 3.6, Student's t-test, P=.017). CONCLUSION: The clinical vignettes presented at the national SGIM meeting offer clinical content that is relevant and of some educational value for third year clerkship students. Based on this pilot study, the educational value and strategies for their use in the clinical clerkships deserve further study.

Using a computer to teach patients about fecal occult blood screening. A randomized trial.

OBJECTIVE: To determine whether a multimedia computer program could effectively teach patients about fecal occult blood testing (FOBT) and increase screening rates. DESIGN: Randomized trial. SETTING: University-affiliated, community-based Internal Medicine outpatient practice. PARTICIPANTS: All English-speaking patients aged 50 years and older who were offered FOBT screening by their providers were invited to participate. Two hundred and four patients enrolled in the study. Ten patients were later determined to be ineligible. INTERVENTIONS: Patients were randomized to either the educational multimedia computer program or usual nurse counseling about FOBT screening. Screening instructions were based on the material pre-printed on each test kit. Educational sessions were held in a private setting immediately after each patient's office visit. MEASUREMENTS AND MAIN RESULTS: A knowledge-assessment questionnaire was administered in a blinded fashion by telephone the following day. Successful screening was defined as return of the test kits within 30 d. Completion of the FOBT kits was similar in both groups: 62% (58/93) in the computer group and 63% (64/101) in the nurse group (P=.89). Mean knowledge scores were also similar, but there was a trend toward increased knowledge mastery in the computer group (56% vs 41%, P=.09). CONCLUSIONS: A multimedia educational computer program was as effective as usual nurse counseling in educating patients and achieving adherence to FOBT screening. Future studies are needed to determine whether computer-assisted instruction can improve health outcomes.

The multimedia computer for office-based patient education: a systematic review.

Use of the multimedia computer for education is widespread in schools and businesses, and yet computer-assisted patient education is rare. In order to explore the potential use of computer-assisted patient education in the office setting, we performed a systematic review of randomized controlled trials (search date April 2004 using MEDLINE and Cochrane databases). Of the 26 trials identified, outcome measures included clinical indicators (12/26, 46.1%), knowledge retention (12/26, 46.1%), health attitudes (15/26, 57.7%), level of shared decision-making (5/26, 19.2%), health services utilization (4/26, 17.6%), and costs (5/26, 19.2%), respectively. Four trials targeted patients with breast cancer, but the clinical issues were otherwise diverse. Reporting of the testing of randomization (76.9%) and appropriate analysis of main effect variables (70.6%) were more common than reporting of a reliable randomization process (35.3%), blinding of outcomes assessment (17.6%), or sample size definition (29.4%). We concluded that the potential for improving the efficiency of the office through computer-assisted patient education has been demonstrated, but better proof of the impact on clinical outcomes is warranted before this strategy is accepted in the office setting.

It's in the cards: a practice-friendly, real-time data collection strategy for quality improvement.

The heart of the Card Response Project, a six-step data collection strategy, is the clinician, armed with a pocket-sized card for rapid completion during clinic visits.

Patient characteristics and clinical management of patients with shoulder pain in U.S. primary care settings: secondary data analysis of the National Ambulatory Medical Care Survey.

BACKGROUND: Although shoulder pain is a commonly encountered problem in primary care, there are few studies examining its presenting characteristics and clinical management in this setting. METHODS: We performed secondary data analysis of 692 office visits for shoulder pain collected through the National Ambulatory Medical Care Survey (Survey years 1993-2000). Information on demographic characteristics, history and place of injury, and clinical management (physician order of imaging, physiotherapy, and steroid intraarticular injection) were examined. RESULTS: Shoulder pain was associated with an injury in one third (33.2% (230/692)) of office visits in this population of US primary care physicians. Males, and younger adults (age < or = 52) more often associated their shoulder pain with previous injury, but there were no racial differences in injury status. Injury-related shoulder pain was related to work in over one-fifth (21.3% (43/202)) of visits. An x-ray was performed in 29.0% (164/566) of office visits, a finding that did not differ by gender, race, or by age status. Other imaging (CT scan, MRI, or ultrasound) was infrequently performed (6.5%, 37/566). Physiotherapy was ordered in 23.9% (135/566) of visits for shoulder pain. Younger adults and patients with a history of injury more often had physiotherapy ordered, but there was no significant difference in the ordering of physiotherapy by gender or race. Examination of the use of intraarticular injection was not possible with this data set. CONCLUSION: These data from the largest sample of patients with shoulder pain presenting to primary care settings offer insights into the presenting characteristics and clinical management of shoulder pain at the primary care level. The National Ambulatory Medical Care Survey is a useful resource for examining the clinical management of specific symptoms in U.S. primary care offices.

Teaching appropriate interactions with pharmaceutical company representatives: the impact of an innovative workshop on student attitudes.

BACKGROUND: Pharmaceutical company representatives (PCRs) influence the prescribing habits and professional behaviour of physicians. However, the skills for interacting with PCRs are not taught in the traditional medical school curriculum. We examined whether an innovative, mandatory workshop for third year medical students had immediate effects on knowledge and attitudes regarding interactions with PCRs. METHODS: Surveys issued before and after the workshop intervention solicited opinions (five point Likert scales) from third year students (n = 75) about the degree of bias in PCR information, the influence of PCRs on prescribing habits, the acceptability of specific gifts, and the educational value of PCR information for both practicing physicians and students. Two faculty members and one PCR led the workshop, which highlighted typical physician-PCR interactions, the use of samples and gifts, the validity and legal boundaries of PCR information, and associated ethical issues. Role plays with the PCR demonstrated appropriate and inappropriate strategies for interacting with PCRs. RESULTS: The majority of third year students (56%, 42/75) had experienced more than three personal conversations with a PCR about a drug product since starting medical school. Five percent (4/75) claimed no previous personal experience with PCRs. Most students (57.3%, 43/75) were not aware of available guidelines regarding PCR interactions. Twenty-eight percent of students (21/75) thought that none of the named activities/gifts (lunch access, free stethoscope, textbooks, educational CD-ROMS, sporting events) should be restricted, while 24.0% (8/75) thought that students should be restricted only from sporting events. The perceived educational value of PCR information to both practicing physicians and students increased after the workshop intervention from 17.7% to 43.2% (chi square, p = .0001), and 22.1% to 40.5% (p = .0007), respectively. Student perceptions of the degree of bias of PCR information decreased from 84.1% to 72.9% (p = .065), but the perceived degree of influence on prescribing increased (44.2% to 62.1% (p = .02)). CONCLUSIONS: Students have exposure to PCRs early in their medical training. A single workshop intervention may influence student attitudes toward interactions with PCRs. Students were more likely to acknowledge the educational value of PCR interactions and their impact on prescribing after the workshop intervention.

A randomised trial of an online lecture with and without audio.

OBJECTIVE: To determine the impact of adding audio-feed to an online lecture on screening given to medical students who were participating in an outpatient clerkship. DESIGN: Prospective, randomised, controlled study. SETTING: Vanderbilt University School of Medicine, Nashville and Wake Forest Medical School, Winston-Salem. PARTICIPANTS: A total of 59 Years 3 and 4 medical students. MAIN OUTCOME MEASURES: Students' use of time, satisfaction with the lecture experience, and knowledge. Educational intervention The online lecture was developed at Vanderbilt University. At Vanderbilt, 16 Year 4 medical students were randomised to the lecture on screening with audio and 17 Year 4 medical students were randomised to the same lecture without audio. At Wake Forest, 13 Year 3 medical students were randomised to the lecture on screening with audio and 13 Year 3 students were randomised to the same lecture without audio. RESULTS: The audio lecture required 20 more minutes to complete than the non-audio lecture. Students in the audio group were more satisfied with their experience than students in the non-audio group. Students in the audio-feed group achieved a trend for higher post-intervention knowledge scores, with the difference attributed to the students at Vanderbilt. CONCLUSION: Audio narration is an important aspect of an online lecture. The distribution of online lectures to students at different sites and different training levels requires further study.

Patient complaints about physician behaviors: a qualitative study.

PURPOSE: Health care institutions are required to routinely collect and address formal patient complaints. Despite the availability of this feedback, no published efforts explore such data to improve physician behavior. The authors sought to determine the usefulness of patient complaints by establishing meaningful categories and exploring their epidemiology. METHOD: A register of formal, unsolicited patient complaints collected routinely at the Wake Forest University Baptist Medical Center in Winston-Salem, North Carolina was used to categorize complaints using qualitative research strategies. After eliminating complaints unrelated to physician behavior, complaints from March 1999 were analyzed (60) to identify complaint categories that were then validated using complaints from January 2000 (122). Subsequently, all 1,746 complaints for the year 2000 were examined. Those unrelated to physician behavior (1,342) and with inadequate detail (182) were excluded, leaving 222 complaints further analysis. RESULTS: Complaints were most commonly lodged by patient (111), followed by a patient's spouse (33), (52), parent (50), relative/friend (15), or health professional (2). The most commonly identified category was disrespect (36%), followed by disagreement about expectations of care (23%), inadequate information (20%), distrust (18%), perceived unavailability (15%), interdisciplinary miscommunication (4%), and misinformation (4%). Multiple categories were identified in (19%) complaints. Examples from each category provide adequate detail to develop instructional modules. CONCLUSION: The seven complaint categories of physician behaviors should be useful in developing curricula related to professionalism, communication skills, practice-based learning.

Recruitment and retention of physicians for primary care research.

The primary objective of this report is to examine factors associated with recruitment of physicians in community-based primary care research. Reported results are based on an observational study of physician recruitment efforts undertaken in a randomized controlled trial designed to improve primary care physicians' cancer screening and counseling activities. The Partners for Prevention project was a statewide randomized controlled trial of primary care physicians selected from the state of Colorado. Two-hundred and ten eligible internal medicine and family medicine practices in both rural and urban community settings of the state of Colorado were selected into this study and a sentinel physician was chosen to represent each practice. Only 6% (13/210) of recruited practices initially declined to participate in the study, but the total refusal rate had reached 30% (59/210) by the time the intervention was implemented five months later. Study participants (n = 136) were younger (mean age 45.7 vs. 50.0, p = 0.008) and more often located in a rural area (46% vs. 31%, p = 0.04) than decliners (n = 59), but there was no association with gender of the physician (87% for females vs. 95% for males, p = 0.13). Participants were more often family practice physicians by training rather than internists (75% vs. 56%, p = 0.008), whereas there was no difference in participation rates by practice type (solo versus group, 60% vs. 64%, p = 0.52). Differences in demographic, geographic, and training characteristics between trial participants and decliners suggest the potential for better targeting of recruitment efforts. Viable strategies for recruiting community-based primary care practices to research studies are proposed.